Family Medicine Update

Attitudes to depression and its treatment in primary care.

Psychol Med. 2007 Jun 11;:1-10

Authors: Weich S, Morgan L, King M, Nazareth I

Background. Undertreatment of depression in primary care is common. Efforts to address this tend to overlook the role of patient attitudes. Our aim was to validate and describe responses to a questionnaire about attitudes to depression and its treatment in a sample with experience of moderate and severe depressive episodes.Method. Cross-sectional survey of 866 individuals with a confirmed history of an ICD-10 depressive episode in the 12 months preceding interview, recruited from 7271 consecutive general practitioner (GP) attendees in 36 general practices in England and Wales. Attitudes to and beliefs about depression were assessed using a 19-item self-report questionnaire.Results. Factor analysis resulted in a three-factor solution: factor 1, depression as a disabling, permanent state; factor 2, depression as a medical condition responsive to support; and factor 3, antidepressants are addictive and ineffective. Participants who received and adhered to antidepressant medication and disclosed their depression to family and friends had significantly lower scores on factors 1 and 3 but higher scores on factor 2.Conclusions. People with moderate or severe depressive episodes have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment.

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Comorbidity and related costs as a burden in the treatment of outpatients with depressive disorders in a primary care setting.

Farm Hosp. 2007 Apr;31(2):101-105

Authors: Sicras Mainar A, Navarro Artieda R, Rejas Gutiérrez J, Blanca Tamayo M, Serrat Tarrés J, Llopart López JR

Objective: To study the impact of depressive disorders (DD) on health care expenditure and to measure associated comorbidity in patients in primary care settings (PCS) under normal clinical practice conditions.Method: A retrospective cohort study was carried out. The study cohort consisted of outpatients aged over 14 years of age with an established diagnosis of DD (ICPC; P76) treated in a PC health centre during 2004. A comparative cohort was formed with the remaining outpatients without DD, treated in that health centre. Main factors for calculation were: age, gender, history/comorbidity and health resource use and the corresponding outpatient costs; drugs, diagnostic tests, visits to specialists and PC physicians. Multiple logistic regression analysis and ANCOVA models were used in order to adjust costs and comorbidities between the cohorts of patients.Results: A total of 64,072 subjects were assessed; 6,592 patients with DD [10.3% (CI: 8.2-12.4%), 74.5% (CI: 73.4%-75.6%) females]. DD outpatients displayed a higher number of episodes of comorbidities/year (mean +/- SD; 7.4 +/- 4.3 vs. 4.7 +/- 3.3, p < 0.0001) and global medical visits/patient/year (12.0 +/- 9.3 vs. 7.4 +/- 7.6, p < 0.0001). The main comorbidities associated to DD were neurological disorders [Odds ratio (95% CI); 2.1 (CI: 1.5-2.6), p < 0.0001], alcoholism [1.6 (CI: 1.3-1.9), p < 0.0001] and malignancies [1.3 (CI: 1.1-1.5), p < 0.0001]. DD were associated with significantly higher adjusted total costs; e 1,083.8 (SEM; e 8.4) vs. e 684.1 (e 3.4), p < 0.0001. Higher costs were displayed for elderly patients. Sixty-two percent of the total cost was related to drugs.Conclusions: Prevalence of DD was higher, particularly in women. Following adjustment in accordance with comorbidity, age and sex, DD outpatients used more health care resources and implied higher costs. Higher costs were associated with age.

17590118

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Late pregnancy bleeding.

Am Fam Physician. 2007 Apr 15;75(8):1199-206

Authors: Sakornbut E, Leeman L, Fontaine P

Effective management of vaginal bleeding in late pregnancy requires recognition of potentially serious conditions, including placenta previa, placental abruption, and vasa previa. Placenta previa is commonly diagnosed on routine ultrasonography before 20 weeks’ gestation, but in nearly 90 percent of patients it ultimately resolves. Women who have asymptomatic previa can continue normal activities, with repeat ultrasonographic evaluation at 28 weeks. Persistent previa in the third trimester mandates pelvic rest and hospitalization if significant bleeding occurs. Placental abruption is the most common cause of serious vaginal bleeding, occurring in 1 percent of pregnancies. Management of abruption may require rapid operative delivery to prevent neonatal morbidity and mortality. Vasa previa is rare but can result in fetal exsanguination with rupture of membranes. Significant vaginal bleeding from any cause is managed with rapid assessment of maternal and fetal status, fluid resuscitation, replacement of blood products when necessary, and an appropriately timed delivery.

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